London nursing home ordered to stop admitting new patients for second time in less than two years

For the second time in 20 months, a London nursing home has been ordered to stop admitting new patients, this time for violations that include turning a blind eye to abuse and allowing a temporary nurse to administer medication under another nurse’s name.

Earls Court Village, which was the target of a rare cease admission order in May 2016, was ordered Tuesday to stop admissions again, and this time it’s not the only home by operator Sharon Village Care Homes that’s the target. Ontario’s Health Ministry has also issued a similar order to Tyndall Seniors Village Retirement and Nursing Home in Mississauga.

Also ordered to cease admissions was Caressant Care Fergus in Wellington County, the sister home to the one in Woodstock where registered nurse Elizabeth Wettlaufer used medication to kill seven patients before killing an eighth in a London home. The killing spree has led a public inquiry. The Woodstock home was ordered in January to stop admitting patients.

This week’s cease admission orders came with a sharp rebuke from Health Minister Eric Hoskins.

“Our thorough inspection regime has identified concerns at Earls Court, Tyndall and Caressant Care Fergus and it is completely unacceptable that these operators are not meeting the province’s standards. The distressing practice of failing to meet provincial standards will not be accepted in Ontario,” Hoskins wrote in a letter obtained by The Free Press.

“As minister, I am acting immediately by ordering these ceases of admissions and clearly outlining my expectations to the sector moving forward. I am prepared to use every tool available to ensure every home in Ontario is a place deserving of our fathers and mothers, brothers and sisters. I will also be writing directly to the presidents of the corporations affected by these ceases of admissions clearly outlining my firm expectations moving forward. I will also be asking them to immediately work with us in raising the quality of care they are providing.”

The order against Earls Court came after inspectors responded to complaints and found 15 violations in August, inspection records show. The findings include:

A registered nurse turned a blind eye toward abuse by one resident against another after it was witnessed by a personal support worker and tried to justify not investigating or reporting the incident because such abuse was too commonplace to report. The nurse went as far as telling the personal support worker that the conduct by the resident was “OK”.

A second incident of abuse, alleged by the family of a resident, went unreported. A registered practical nurse told inspectors she reported concerns to a registered nurse, but the latter claimed that never happened. A similar pattern occurred in January 2016, an inspector reported.

A resident who saw another resident abuse a third resident said they reported what was seen to the assistant director of care, even providing a letter, but the assistant did not give the letter to the director of care. The assistant claimed the letter had nothing to do with abuse, and that the letter has been shared with the director, but the latter was unable to find the letter to show the inspectors. A similar pattern previously led to compliance orders twice in 2016.

The home hired staff before police did a criminal background check, a practice that previously led to a ministry order in March 2015.

A nurse with only four hours of orientation training with the home made medication mistakes twice in their first shift and recorded what they’d done electronically using the name and login number of an experienced registered nurse, who in turn signed the electronic records as if she had given the medications.

Residents and their families complained about under-staffing and the owner of the home admitted he has let 10 frontline positions go unfilled for a period of time, creating a shortfall of nurses and personal support workers to look after residents. The home’s owner blamed scheduling mistakes on management turnover as it took time to find and train replacements. But managers themselves said they left because the home placed on them impossible demands and workloads; the assistant director and managers of activity and dietary services resigned while the director took a nearly month-long leave in August. A registered nurse filled in for her for five shifts while trying to do her own duties at the same time. The administrator said she asked the home’s owner to hire more full-timers rather than part-time and temporary workers, and to over-staff at times when sick days were more likely, but the owner refused, citing budgetary concerns, including a desire not to have to provide benefits.

The lack of staffing led to many complaints. A resident who was normally continent but needed help to get to the bathroom said they repeatedly were left to soil and wet their clothes because that area of the home was so chronically short of staff that those who worked were slow to respond to a call bell. Records showed staff regularly took between 13 and 36 minutes to respond to call bells for one resident, and 10 to 26 minutes for a second resident. A third resident said there was chronic understaffing on weekends so residents had to wait an extra hour to be fed or to be changed from a soiled brief. A review from an inspector found staff had failed to respond 42 times for toileting needs alone. A fourth resident said they was left to soak in their own urine, and that staff changed the type of adult diaper to be used to one that could hold more urine because staff could not change the diapers at the required frequency.

Inspectors found staff failed to check on or record the safety of restraints on residents nearly one-quarter of the time.

Staff admitted they were too hard-pressed for time to regularly bathe and reposition a resident in bed, leading to skin sores. A personal support worker told inspectors the home was short of staff almost very day and that it was especially bad on weekends. A registered nurse said staff shortages placed residents at risk. Needed tasks were done as much as an hour late, including administering medication. When the owner, who was in the home, was told by staff of concerns, he told them “to do what they could and finish on time.” Similar problem with understaffing was found by inspectors in 2014 and twice in 2016.

Medication carts were left unlocked and unattended in a hallway and by the dining room and staff said intermittent problems with the locking mechanisms were a chronic issue known to staff. An administrator admitted it was practice for staff to push locks in only halfway so they wouldn’t need a key to unlock it later. Similar problems were found by inspectors in each of the past two years.

Asked about the orders and finding, the president and CEO of Sharon Village Care Homes, Peter Schlegel, said he never told managers that he wouldn’t adjust how he staffed the home because of budgetary concerns, and that while it’s true he didn’t pay part-timers benefits, those part-timers received extra pay instead of benefits.

“We’re much more concerned about the continuity of care,” he said of Earls Court at 1390 Highbury Ave. N.

Asked about findings that Earls Court was chronically short of staff, Schlegel said he disagreed. “We’ve had some staffing issues, but it’s not about understaffing.”

As for the high turnover of senior managers, Schlegel said the situation was more complex than the ministry inspectors reported. He also said findings of substandard care were to some degree the subjective views of inspectors.

Schlegel said he would email a fuller statement to The Free Press Wednesday afternoon

In March 2016, inspectors published a report that found 37 violations and issued 16 orders, many repeat orders since Earls Court Village opened in 2014. The home was cited then for many of the same sort of failings that turned up again in August: not investigating or reporting suspected abuse, providing negligent care, allowing residents to fester in soiled beds and clothes, and doing nothing in the face of repeated orders to clean up its act.

Caressant Care owns nine nursing homes in Ontario, including five in the London region, while Sharon Village Care Homes owns four nursing home, including two in London – the other being Kensington Village.

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